Healthcare Provider Details

I. General information

NPI: 1235741679
Provider Name (Legal Business Name): BENJAMIN BERTHOLD PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2020
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5770 S 1500 W
SALT LAKE CITY UT
84123-5216
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 801-265-3412
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number14241564-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number286456
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number14241564-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: